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Am Fam Physician. 2001;63(6):1048-1050

to the editor: Why does the American Academy of Family Physicians (AAFP) advocate performing Papanicolaou (Pap) tests in all women at age 18 regardless of their sexual activity status? The young woman who presents without a history of previous sexual activity does not need to undergo a Pap test. The Pap test is a screening test for cervical cancer and precancerous conditions. Human papillomavirus (HPV) is virtually the sole cause of cervical cancer and is sexually transmitted. The woman who has had no sexual experience is at extremely low or no risk for cervical cancer. Why advocate screening in this group?

Another area that puzzles me is Pap screening in women who have undergone total hysterectomy. I see this testing being done in clinics and observe physicians who say, “Just do it” to residents in training, but I do not see the point. These women have no cervices. What is the purpose of a screening test when the organ is not present? I am aware that, occasionally, vaginal abnormalities are discovered; a high degree of suspicion may be present from the physical examination and/or history in these cases. The Pap test then becomes a test to confirm an abnormality found on physical examination—not a screening test.

Finally, why continue Pap test screening in women older than 65 years who have no sexual contact or who have had the same partner and many previous Pap tests that were within normal limits?

I stress that in all these situations, I speak of performing screening Pap tests as probably being performed unnecessarily, and do not refer to those persons where the medical history and physical examination prompts the physician to conduct appropriate testing.

editor's note: The American Academy of Family Physicians (AAFP) recommends Pap test screening for all women who are sexually active or who have a cervix, but the recommendations do not specify a lower or upper age limit. The U.S. Preventive Services Task Force 1996 Guidelines1 make a similar recommendation, but include that adolescents who are thought to be unreliable should be presumed to be sexually active at the age of 18.

As for the issue of Pap screening in women who have undergone total hysterectomies, the U.S. Preventive Services Task Force 1996 Guidelines1 further state that post-hysterectomy Pap screening is of no benefit—unless the hysterectomy was performed for cervical cancer. Post-hysterectomy Pap tests may detect vaginal cancer, but the yield and predictive value are low, and the test was never designed for this purpose.

Finally, the U.S. Preventive Task Force 1996 Guidelines1 state that there is insufficient evidence to recommend an upper age limit for Pap screening. However, they acknowledge that a recommendation can be made to discontinue Pap tests in women older than 65 years who have had regular previous Pap tests that were within normal limits. Continued Pap testing in women at the age of 65 reduces their risk of death from cervical cancer by only 0.18 percent, and by the age of 74, the risk reduction is only 0.06 percent.

The AAFP recommendations for Pap screening are currently under review.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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Copyright © 2001 by the American Academy of Family Physicians.

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